🩺 Record Detail
Patient Info
Name: Simlen Parveen
Age: 29 years
Date: 2025-05-30 13:21:14
Transcript
[00:00 → 00:05] We are coming, Doctor. [00:05 → 00:06] Yes, come in. [00:06 → 00:08] Take your seat. [00:08 → 00:10] Thank you, Doctor. [00:10 → 00:12] What's your name? [00:12 → 00:15] Simlen Parveen. [00:15 → 00:17] And how old are you? [00:17 → 00:20] I'm 29. [00:20 → 00:21] Okay. [00:21 → 00:22] Now, tell me. [00:22 → 00:25] What are the problems that you're facing? [00:25 → 00:27] Since you're still in night, [00:27 → 00:29] I've been having serious stomachache. [00:29 → 00:31] I took an antested last night, [00:31 → 00:34] but the pain was still the same. [00:34 → 00:37] Hmm. Any other symptoms? [00:37 → 00:40] Yeah, I also had about some vomit in last night. [00:40 → 00:43] And studio morning as well. [00:43 → 00:46] Do you have a headache? [00:46 → 00:48] No. [00:48 → 00:52] Did you have this kind of stomachache before? [00:52 → 00:54] Yes, Doctor. [00:54 → 00:56] I had it worse before. [00:56 → 00:58] How many days ago? [00:58 → 01:00] Almost three months ago. [01:00 → 01:05] But at that time, the pain stopped after I took an antested. [01:05 → 01:07] Please lie on that bed. [01:07 → 01:09] I have to check. [01:09 → 01:12] Okay, Doctor. [01:22 → 01:24] Does it hurt here? [01:24 → 01:25] Yes, Doctor. [01:25 → 01:26] It hurts a lot. [01:26 → 01:29] Okay, you can get it now. [01:29 → 01:33] Is it something serious, Doctor? [01:33 → 01:35] I can't say now. [01:35 → 01:37] I'm writing down some tests. [01:37 → 01:39] Try to do this by today. [01:39 → 01:41] But what about now? [01:41 → 01:44] I can't even work properly because of the pain. [01:44 → 01:45] I understand. [01:45 → 01:49] I'm giving you an injection for temporary relief. [01:49 → 01:51] Injection? [01:51 → 01:55] Don't you have any medicine? [01:56 → 01:57] Why? [01:57 → 01:59] Are you scared of injections? [01:59 → 02:01] It's not like that. [02:01 → 02:06] I mean, it would be better if you could give me some medicine. [02:06 → 02:07] Nothing will happen. [02:07 → 02:09] You won't even feel it. [02:09 → 02:11] Look at that side. [02:11 → 02:13] Please, Doctor. [02:13 → 02:15] Be careful. [02:15 → 02:18] You can open your eyes now. [02:18 → 02:21] It's already done. [02:21 → 02:23] It's done. [02:23 → 02:24] Thank you so much. [02:24 → 02:27] I did not feel anything at all. [02:27 → 02:32] After receiving the test reports, bring them to me as soon as possible. [02:32 → 02:35] So, there's nothing to fear, right? [02:35 → 02:37] Don't be so scared beforehand. [02:37 → 02:39] Let's see the reports first. [02:39 → 02:42] You want to give me any medicines, Doctor? [02:42 → 02:43] Hmm. [02:43 → 02:45] I'm prescribing this medicine. [02:45 → 02:47] It's just for today. [02:47 → 02:49] Take it after your dinner. [02:49 → 02:51] Okay, Doctor. [02:51 → 02:53] Where shall I submit the fees? [02:53 → 02:56] Please submit that in the cash counter. [02:56 → 02:58] Thank you, Doctor. [02:58 → 02:59] Welcome.
Clinical Notes
Subjective
-
Patient: Simlen Parveen, 29 years old.
-
Primary Concern:
-
Presenting with severe stomachache since last night, despite taking an antacid.
-
Experienced vomiting last night and this morning.
-
Previous history of similar stomachache three months ago, relieved with antacid.
Objective
- No relevant data.
Assessment
- Gastric Pain: Acute onset of severe stomachache with associated vomiting, warranting further investigation.
Plan
-
Diagnostics:
-
Order tests to investigate the cause of stomach pain.
-
Treatment:
-
Administered an injection for temporary relief.
-
Prescribed medication to be taken after dinner for the day.
-
Follow-Up:
-
Instructed the patient to bring test reports promptly for review.
-
Financials:
-
Directed the patient to submit fees at the cash counter.